Knee Surgery, Sports Traumatology, Arthroscopy最新文献

Purpose: The stability of the graft in the bony tunnels is of utmost importance in the anterior cruciate ligament reconstruction (ACLR) since it ensures safe healing at the tendon-bone interface. The hypothesis was that when a double tibial fixation was used in ACLR with a short graft of autologous hamstrings, tibial tunnel bone re-growth and better graft integration would be observed at short-term follow-up.

Methods: The analysis included a cohort of 112 patients after a primary ACLR with hamstring tendons who underwent postoperative magnetic resonance imaging (MRI) 3.0-Tesla (3.0-T) 6 months after the surgery. The patients were divided into three groups based on the tibial fixation technique: 40 had a screw (group S), 35 had a screw and cortical button (group S + B) and 37 had a screw and anchor (group S + A). Two orthopaedic specialists independently evaluated the images, who measured the screw-free tunnel space, and assessed the presence of bone filling in the free tunnel. Furthermore, Ge's protocol was used to determine the graft healing in the tunnel.

Results: In 94 patients a screw-free tunnel space was detected, and a filling of the tunnel was reported in 80.85% of the cases (76 patients), being partial in 15.79% (12 patients) and complete in 84.21% (64 patients). Patients who presented better graft integration (Ge1) had significantly higher values of screw-free tunnel length compared to the other ones who had lower graft integration (Ge3)(p < 0.05).

Conclusions: At 6 months postoperative MRI, tibial tunnel bone re-growth and graft-tunnel tibial integration after hamstring ACLR is significantly associated with the presence of free space between the anterior tibial cortex and the most distal portion of the interference screw, hence the use of a short and proximalized interference screw is suggested to restore bone stock after hamstring ACLR.

Level of evidence: Level IV retrospective comparative cohort study.

Purpose: Much debate exists about the superiority of navigated versus conventional instrumentation for achieving optimal balance and alignment during total knee arthroplasty (TKA). Recent registry data indicate no long-term survivorship benefit for TKAs performed using technology assistance, despite the added resource and financial costs. However, outcome comparisons are confounded by varying surgeon techniques and targets for ideal balance and alignment. This study aimed to investigate alignment or balance outcome differences between navigated and conventionally instrumented TKAs performed using an identical operative sequence and alignment strategy.

Methods: Fifty navigated and 50 conventionally instrumented primary TKAs, using an identical inverse kinematic alignment strategy, were included. Navigation equipment was used intraoperatively to 'post-cut' record the conventionally instrumented TKAs. Intraoperative balance, range, and alignment; and post-operative radiographic accuracy for restoration of constitutional alignment were compared.

Results: Forty-nine navigated and 49 conventionally instrumented TKAs were compared (n = 2 excluded due to inadequate radiographs). No preoperative demographic or deformity severity differences existed. No intraoperative balance, range or alignment difference existed. Neither technique was more accurate for restoration of constitutional alignment.

Conclusion: Whilst large registry data may be confounded by uncaptured variables such as surgeon balancing techniques or surgeon alignment strategy preferences, this study found no alignment or balance differences between navigated versus conventionally instrumented TKA techniques for a surgeon and technique-controlled study. Although the increased resources necessary for technology assistance are not justified by this study, further studies may identify significance using larger samples or comparison of alternative outcomes.

Level of evidence: Level II.

Purpose: The significance of the posterior tibial slope (PTS) has increasingly come into focus in anterior cruciate ligament (ACL) reconstruction being a risk factor for ACL graft failure. Nevertheless, inconsistent data on the critical value of the PTS exist. The purpose of this study was to define a cut-off value for the PTS in ACL surgery.

Methods: In a retrospective cohort study, 350 revision ACL reconstructions (ACL-RR) with a failed ACL hamstring graft and 350 primary ACL reconstructions (ACL-R) were matched according to age, gender, concomitant injuries and graft characteristics and compared to a healthy control group. Using the proximal anatomic axis, lateral knee radiographs were evaluated for the PTS, interrater reliability was defined, ROC curves, Fischer's exact test and Baptista-Pike method were applied to define specificity and the odds ratio for a critical PTS value.

Results: Radiographic evaluation proved excellent interrater reliability (intraclass correlation coefficient 0.969). Evaluation of the PTS revealed 10.0 ± 2.2 (5-15) degrees in the ACL-RR group, 7.8 ± 1.8 (4.2-13) degrees in the ACL-R group and 6.6 ± 1.9 (3.6-12) degrees in the control group with significant differences between the groups (p < 0.001). A PTS value of 10.1 degrees proved a specificity of 98% for the prediction of an ACL graft failure and indicated an 11-fold risk for a retear of the ACL.

Conclusion: A PTS exceeding 10.1 degrees carries an 11-fold risk for ACL graft failure and, therefore, should be considered in ACL reconstruction. These findings might serve as a cut-off value for the indication of a slope-reducing high tibial osteotomy in ACL surgery.

Level of evidence: Level III.

Purpose: The purpose of this study was to predict high-risk patients who experience significant increases in hospital charges and length of stay (LOS) following specific postoperative complications.

Methods: This study analyzed over two million patients from the Nationwide Inpatient Sample database undergoing elective total knee arthroplasty (TKA) for primary osteoarthritis. Baseline demographics, clinical characteristics and incidence of postoperative complications were examined. A neural network model was utilized to predict high-risk patients who fall into the top 25% for both LOS and total hospital charges after complications such as sepsis or surgical site infection (SSI).

Results: The most common complications were blood loss anaemia (14.6%), acute kidney injury (1.6%) and urinary tract infection (0.9%). Patients with complications incurred significantly higher total charges (mean $66,804) and longer LOS (mean 2.9 days) compared to those without complications (mean $58,545 and 2.1 days, respectively). The neural network model demonstrated strong predictive performance, with an area under the curve of 0.83 for the training set and 0.78 for the testing set. Key complications like sepsis and SSIs significantly impacted hospital charges and LOS. For example, a 57-year-old patient with diabetes and sepsis had a 100% probability of being in the top 25% for both total charges and LOS.

Conclusion: Postoperative complications in TKA patients significantly increase hospital charges and LOS. The neural network model effectively predicted high-risk patients after specific complications occurred, offering a potential tool for improving patient management and resource allocation.

Levels of evidence: Level III.

Purpose: This umbrella review aimed to identify, synthesise and critically appraise the findings of meta-analyses that compare adverse events-rates of complications, reoperations and revisions-following total knee arthroplasty (TKA) using unrestricted kinematic alignment versus mechanical alignment.

Methods: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria, two authors independently screened articles based on inclusion and exclusion criteria, and assessed the methodological quality based on the 16 domains of A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2). Effect sizes of difference in rates of complications were tabulated for each meta-analysis. Studies included in the meta-analyses were assessed to determine if they were on true unrestricted kinematic alignment. A secondary meta-analysis was performed, excluding studies on restricted kinematic alignment techniques, to calculate pooled estimates of adverse events (odds ratio [OR] with its 95% confidence interval [CI]) in a common effects framework with inverse-variance weighting.

Results: Of 78 potential records, 13 meta-analyses were eligible for data extraction, which pooled data from 15 clinical studies (10 on unrestricted kinematic alignment, four on restricted kinematic alignment and one on inverse kinematic alignment). None of the meta-analyses fulfilled all seven critical AMSTAR-2 domains. Meta-analyses categorised adverse events differently and used different measures for the effect sizes but revealed no differences between kinematic versus mechanical alignment. Exclusion of studies on restricted kinematic alignment techniques reduced total sample sizes for kinematic alignment from 658 to 318 and for mechanical alignment from 811 to 403. Secondary meta-analyses exclusively on unrestricted kinematic alignment revealed no difference in complications without reoperation, reoperation without implant removal or reoperation with implant removal following kinematic versus mechanical alignment.

Conclusion: Meta-analyses do not distinguish between various kinematic alignment techniques, and adverse events are compared using different metrics. Surgeons, researchers and editors should refrain from pooling data on various kinematic alignment techniques, and orthopaedic societies should promote standards for reporting adverse events and effect sizes to facilitate comparisons across future studies.

Level of evidence: Level III.

Purpose: This systematic review with meta-analysis evaluates the long-term efficacy of matrix-assisted autologous chondrocyte transplantation (MACT) in terms of functional scores using scaffolds made of hyaluronic acid (HA) or collagen (C).

Methods: Nineteen articles met the eligibility criteria for the analysis. Fourteen studies focused on patients treated with MACT with HA-based scaffolds, four studies with C-based scaffolds, and one study compared both scaffold types.

Results: A higher percentage of patients in the HA subgroup had undergone previous cartilage repair procedures, whereas multiple lesions were more common in the C subgroup. Both HA- and C-treated patients showed significant functional improvement in terms of International Knee Documentation Committee with overall mean differences at 2 and 5 years, and for HA-treated patients at 10 years. Likewise, concerning the Tegner activity scale, both subgroups demonstrated significant improvement at 2 years, with the HA subgroup showing more sustained improvement up to 10 years. The HA subgroup also had EQ-VAS reduction at 2, 5 and 10 years. Failure rates were similar between and within groups, with a range from 0% to 42% at different follow-ups.

Conclusion: Patients experienced mid-term benefits from MACT, using both HA-based and C-based scaffolds, and long-term benefits from using HA-based scaffolds. The low failure rate and the fact that most patients did not require knee replacement surgery are encouraging. Accordingly, despite their complexity and high costs, regenerative techniques like MACT are effective, as they can significantly delay or even prevent the need for total knee replacement.

Level of evidence: Level IV.

Purpose: The main purpose was to determine cut-off values for absolute (Q_Nm/kg) and relative (Q_LSI) isokinetic knee extensor (KE) strength for achieving a patient-acceptable symptom state (PASS) in the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and for different age groups to determine the association between Q_Nm/kg and Q_LSI and PASS, at 1 and 3 years after an anterior cruciate ligament reconstruction (ACLR).

Methods: PASS was defined as reaching cut-off values for all KOOS subscales. Data from follow-ups were extracted from a rehabilitation registry. Male and female patients were divided into two age groups based on their age at primary ACLR: 16-24 years and 25-65 years. Odds Ratios between the Q_Nm/kg and Q_LSI cut-off values and achieving PASS were calculated. Receiver Operating Characteristic curves were constructed to determine the individual predictive capacity for achieving PASS of Q_Nm/kg and of Q_LSI using the area under the curve (AUC).

Results: Results from 755 and 145 patients (females = 51% and 52%; preinjury Tegner Activity level ≥6 = 82% and 74%) were used in the 1- and 3-year follow-up analyses. Reaching the cut-off values for the Q_Nm/kg, ranging between ≥2.1 and ≥2.7, entailed between 2.09 and 5.12 times the odds of achieving PASS, across all groups at the 1-year follow-up. At the 3-year follow-up, the cut-off values of ≥3.4 and ≥2.6Q_Nm/kg were associated with patients achieving PASS with acceptable accuracy (AUC = 0.700-0.780) in 16-41 year-old males and females.

Conclusion: At 1 year after ACLR, patients of both sexes and age groups reaching cut-off values for absolute KE strength had two to five times the odds, that were clinically relevant, to achieve PASS. Acceptable discriminative capacity was found for the absolute KE strength among male and female patients 16-24 years old, at 3 years after ACLR.

Level of evidence: Level III.

Purpose: To adapt the current D. Dejour trochlear dysplasia classification (v2.0) to only rely on quantitative magnetic resonance imaging (MRI) measurements (v3.0) to maximize objectivity and repeatability.

Methods: A consecutive series of adult knee MRIs were divided into objective patellar instability (OPI, n = 127) or controls (n = 103; isolated meniscal tears) and postprocessed with multiplanar reconstruction (MPR) to standardize the sagittal plane and ensure true lateral views. Thresholds for sulcus angle, lateral trochlear inclination (LTI) and central bump were established using regression tree models to distinguish OPI from controls. The sensitivity and specificity of sulcus angle and LTI combinations to diagnose OPI were then evaluated, and the combination yielding the highest sensitivity was selected as basis for trochlear dysplasia classification. Finally, sulcus angle and LTI measurability and presence of a central bump >5 mm were used to grade dysplasia as low, moderate or high.

Results: The regression tree models produced thresholds of ≥157° for sulcus angle and <14° for LTI to distinguish OPI from controls. 'Sulcus angle ≥157° OR LTI < 14°' yielded the highest sensitivity (87%) to diagnose OPI. The quantitative MRI classification was sulcus angle <157° AND LTI ≥ 14° for Type 0 (No dysplasia); (sulcus angle ≥ 157° OR LTI < 14°) AND central bump <5 mm for Type 1 (Low-grade dysplasia); (sulcus angle OR LTI are 'unmeasurable') AND central bump <5 mm for Type 2 (Moderate-grade dysplasia); (sulcus angle ≥ 157° OR 'unmeasurable' OR LTI < 14° OR 'unmeasurable') AND central bump ≥5 mm for Type 3 (High-grade dysplasia).

Conclusion: This MRI classification depends exclusively on quantitative measurements, has excellent interobserver agreement, and yields high sensitivity to diagnose OPI. The MRI imaging protocol with MPR mode and standardized measurements could be quickly adopted and correctly applied by clinicians worldwide in any type of institution to determine the ideal treatment plan.

Level of evidence: Level III.